Document Assessments and Plans

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Open the Assessments Tab

You can open the assessment tab using Add or Update Assessment template. Open NextGen® Enterprise EHR. Open the SOAP template, then in the Assessment/Plan section, select Add Assessments.The Add or Update Assessment template set opens. Optional: From the Intake or SOAP template, select the My Plan, and then select Assesments.The Add or Update Assessment template set opens. Sorting Assessments You can update the order of the assessments for a patient in the Reorder Assessments template. Convert ICD Codes in the Billing History Remove an Assessment from Add or Update Assessment Template You can remove an assessment from the Today's Assessment grid in theAdd or Update Assessment template. Documenting Assessment Plan Details You can document your impressions and comments, differential diagnoses, and patient or provider plan details for an assessment using the A/P Details tab. Links and Buttons on the A/P Details Tab You can document the A/P Details tab using the available links and buttons

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Enter Assessment Plan Details

Open NextGen® Enterprise EHR. On the Assessment Plan Details template, select the A/P Details tab. To add or change a diagnosis in the Today’s Assessments grid, select Add or Edit to open the Add or Update Assessment template. To change the current working assessment, in the Today's Assessments grid, select the diagnosis being addressed for this encounter. The selected diagnosis appears in the Selected Dx field. It becomes the new working assessment that carries forward to the other templates that share the assessment. Enter details manually or use My Phrases or Common Phrases for the impression, differential diagnosis, and patient and provider plans in the respective sections. To enter follow-up appointment and disposition information, select Follow Up. To document counseling educational details and factors, select the Counseling Details link. To enter post-operative details, select the Postoperative Quality Reporting link. For more information on the associated quality measure, selec

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Review a Patient's Symptoms for Various Systems

As part of the provider workflow, you can review and update symptoms entered during the patient's intake. Open NextGen® Enterprise EHR. Open the SOAP template, and then expand the Review of Systems panel. To select a default set of findings, select an appropriate value in ROS Defaults. Note: You can also select Load to quickly load any saved review of systems, or select Save to save the documented review of systems to use them on other encounters. To document symptoms for multiple systems on a single template, select One Page ROS from the left navigation bar. Note: You can configure the One Page ROS link to open a gender-specific or gender-neutral template by using the Framework Content template. You can also customize the label for the One Page ROS link. To document findings for a single system, select an appropriate link from the left navigation bar. To copy review of systems from a previous encounter to the current encounter, select ROS History.If you have copied and edited informat

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Enter an Order

You can enter and place an order from the My Plan or My Custom Plan template. Open NextGen® Enterprise EHR. Open the Intake template or SOAP template. Expand the Orders panel and select Add Orders.Based on the setting done on the Practice Configuration template, the My Plan or My Custom Plan template opens. My Custom Plan sections If required, add an assessment.The My Plan template is part of a group of templates that use the last assessment or diagnosis selected on any of the templates in the group as the working assessment. The system defaults to the current working assessment. You can select another assessment, which becomes the new working assessment that carries forward to the other templates in the group. The selected assessment appears in the Selected Dx field. If required, select the Assessments, My Plan, A/P Details, Labs, Diagnostics, Referrals, Office Procedures, and Review/Cosign Orders tabs to enter the appropriate information for each. Note: Select the Quality button on t

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Add Birth Control Information

Ensure that Title X fields are configured in the Practice Configuration template. Open NextGen® Enterprise EHR. Select a patient, create an encounter and then select the Specialty as Family Practice and Visit Type as Office Visit. On the SOAP template, expand the Assessment / Plan panel. To include the confidential details in the master documents, select the Include all Title X contraception information in the document with patient permission checkbox. To add a reason for not mentioning Birth Control Information (BCM), click Reason for No Birth Control Method at End of Visit. To add a contraception method, click Contraception Provision Method. To add or update BCM, click Birth Control Information at End of Visit. Note: You can add up to two birth control methods. Save the changes. Parent topic: Configure Title X in Assessment / Plan

NextGen® Adaptive Content Engine Help Enterprise 8.3.1

Copy Assessments from Previous Encounters

You can copy assessments from previous encounters of a patient to the current encounter instead of manually adding them. Open NextGen® Enterprise EHR. Open the SOAP template, and then expand the Assessment/Plan panel. Select Dx/AP History.The Assessment, Diagnosis Copy Forward window opens. Note: By default, the All Assessments option is selected and records are displayed for the default duration configured in the Copy Previous Visit Information section of the Practice Configuration template. To copy assessments from a specific encounter, select Encounter Assessments. To filter the records in the grid, enter the search criteria in Filter by, and then select Search. Note: If the records are displayed from any sensitive encounter, an asterisk (*) appears on the record in the Sensitive column to help you decide whether to copy such records and update the current encounter as sensitive. To select an assessment, do one of the following: From the All Assessments grid, select the record, and

Document Assessments and Plans

Recommendations

Open the Assessments Tab

Enter Assessment Plan Details

Review a Patient's Symptoms for Various Systems

Enter an Order

Add Birth Control Information

Copy Assessments from Previous Encounters

Open the Assessments Tab

Enter Assessment Plan Details

Review a Patient's Symptoms for Various Systems

Enter an Order

Add Birth Control Information

Copy Assessments from Previous Encounters